Anatomical Variations That Can Lead to Spine Surgery at The Wrong Level: Part II Thoracic Spine

Shah, Manan; Halalmeh, Dia R.; Sandio, Aubin; Tubbs, R. Shane; Moisi, Marc

doi:10.7759/cureus.8684

Cited by 24 publications

(27 citation statements)

References 21 publications

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“…The sacralized vertebra now represents the first sacral vertebra. This phenomenon is recognized in the general population with a prevalence of 4%-30% [6][7][8][9] In 1984, Castellvi et al created a classification system for the types of LSTV based on morphology [11]. Type I includes unilateral (Ia) or bilateral (Ib) dysplastic transverse processes that are at least 19 mm wide (craniocaudal dimension); type II includes incomplete unilateral (IIa) or bilateral (IIb) lumbarization/sacralization with an enlarged transverse process forming a diarthrodial joint with lateral mass of the sacrum; type III includes unilateral (IIIa) or bilateral (IIIb) lumbarization/sacralization with complete osseous fusion of the transverse process(es) to the sacrum, and type IV involves a unilateral type II transition with a type III on the contralateral side [8].…”

Section: Figure 1: Sacralization Of the Fifth Lumbar Vertebraementioning

confidence: 97%

“…Occasionally, identification of the target lumbar level intraoperatively can be complicated by this type of vertebral anomalies; therefore, care must be taken when using x-rays. As with hemivertebrae in the cervical and thoracic spine, preoperative imaging, particularly CT scan, may be performed to facilitate identification of the proper level [6,26]. Anterior hemivertebrae are associated frequently with a posterior hemilamina located one level cephalad [27].…”

Section: Hemivertebramentioning

confidence: 99%

“…The disparity between the disc height in congenital block vertebrae and acquired fused vertebrae can lead to uncertainty about the spinal level. Furthermore, inability to identify a block or fused vertebra may result in an enumeration error that can lead to surgery at the wrong level [6,26]. In addition, this fusion can disturb the normal anatomical angle of the spine, which complicates the approach further [28].…”

Section: Hemivertebramentioning

confidence: 99%

“…Neoplasms located in the spine, importantly metastatic foci from distant tumors with a predilection for lumbosacral region, can change the anatomical structure of vertebral bodies, thereby hinder identification of the target level on imaging [6,26]. Similarly, vertebral infections (e.g., osteomyelitis/diskitis) result in the destruction of the vertebral bodies.…”

Section: Tumors and Infectionmentioning

confidence: 99%

“…Similarly, vertebral infections (e.g., osteomyelitis/diskitis) result in the destruction of the vertebral bodies. Chronic infections can cause the vertebral bodies to fuse; therefore, meticulous evaluation of preoperative imaging should be performed to avoid surgical errors [6,26].…”

Section: Tumors and Infectionmentioning

confidence: 99%

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Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part III Lumbosacral Spine

Shah¹,

Halalmeh²,

Sandio³

et al. 2020

Cureus

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Spine surgery at the wrong level is an undesirable event and unique pitfall in spine surgery. It is detrimental to the relationship between the patient and the surgeon and typically results in profound medical and legal consequences. It falls under the wrong-site surgery sentinel events reporting system. This error is most frequently observed in lumbosacral spine. Several risk factors are implicated; however, anatomical variations of the lumbosacral spine are a major risk factor. The aim of this article was to provide a detailed description of these high-risk anatomical variations, including transitional vertebrae, lumbar ribs, butterfly vertebrae, hemivertebra, block/fused vertebrae, and spinal dysraphism. A literature review was performed in the database PubMed to obtain all relative English-only articles concerning these anatomical variations and their implication in the development of lumbosacral spine surgery at the wrong level. We also described patient characteristics that can lead to lumbosacral surgery at the wrong level such as tumors, infection, previous lumbosacral surgery, obesity, and osteoporosis. Certain techniques to prevent such incorrect surgery were explained. Lumbosacral spine anatomical variations are surgically significant. Awareness of their existence may provide better pre-operative planning and surgical intervention, leading to avoidance of incorrect-level surgery and potentially better clinical outcomes. In addition, collaboration with radiologists and careful examination of patient's anatomy and characteristics should be exercised, especially in difficult cases.

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Section: Figure 1: Sacralization Of the Fifth Lumbar Vertebraementioning

confidence: 97%

Section: Hemivertebramentioning

confidence: 99%

Section: Hemivertebramentioning

confidence: 99%

Section: Tumors and Infectionmentioning

confidence: 99%

Section: Tumors and Infectionmentioning

confidence: 99%

See 3 more Smart Citations

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part III Lumbosacral Spine

Shah¹,

Halalmeh²,

Sandio³

et al. 2020

Cureus

Self Cite

View full text Add to dashboard Cite

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Definition of Normal Vertebral Morphometry Using NHANES‐II Radiographs

Hipp¹,

Grieco²,

Newman³

et al. 2022

JBMR Plus

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A robust definition of normal vertebral morphometry is required to confidently identify abnormalities such as fractures. The Second National Health and Nutrition Examination Survey (NHANES-II) collected a nationwide probability sample to document the health status of the United States. Over 10,000 lateral cervical spine and 7,000 lateral lumbar spine X-rays were collected. Demographic, anthropometric, health, and medical history data were also collected. The coordinates of the vertebral body corners were obtained for each lumbar and cervical vertebra using previously validated, automated technology consisting of a pipeline of neural networks and coded logic. These landmarks were used to calculate six vertebral body morphometry metrics. Descriptive statistics were generated and used to identify and trim outliers from the data. Descriptive statistics were tabulated using the trimmed data for use in quantifying deviation from average for each metric. The dependency of these metrics on sex, age, race, nation of origin, height, weight, and body mass index (BMI) was also assessed. There was low variation in vertebral morphometry after accounting for vertebrae (eg, L1, L2), and the R 2 was high for ANOVAs. Excluding outliers, age, sex, race, nation of origin, height, weight, and BMI were statistically significant for most of the variables, though the F-statistic was very small compared to that for vertebral level. Excluding all variables except vertebra changed the ANOVA R 2 very little. Reference data were generated that could be used to produce standardized metrics in units of SD from mean. This allows for easy identification of abnormalities resulting from vertebral fractures, atypical vertebral body morphometries, and other congenital or degenerative conditions. Standardized metrics also remove the effect of vertebral level, facilitating easy interpretation and enabling data for all vertebrae to be pooled in research studies.

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Development and interinstitutional validation of an automatic vertebral‐body misalignment error detector for cone‐beam CT‐guided radiotherapy

et al. 2022

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Background: In cone-beam computed tomography (CBCT)-guided radiotherapy, off -by-one vertebral-body misalignments are rare but serious errors that lead to wrong-site treatments. Purpose: An automatic error detection algorithm was developed that uses a three-branch convolutional neural network error detection model (EDM) to detect off -by-one vertebral-body misalignments using planning computed tomography (CT) images and setup CBCT images. Methods: Algorithm training and test data consisted of planning CTs and CBCTs from 480 patients undergoing radiotherapy treatment in the thoracic and abdominal regions at two radiotherapy clinics. The clinically applied registration was used to derive true-negative (no error) data. The setup and planning images were then misaligned by one vertebral-body in both the superior and inferior directions, simulating the most likely misalignment scenarios. For each of the aligned and misaligned 3D image pairs, 2D slice pairs were automatically extracted in each anatomical plane about a point within the vertebral column. The three slice pairs obtained were then inputted to the EDM that returned a probability of vertebral misalignment. One model (EDM 1 ) was trained solely on data from institution 1. EDM 1 was further trained using a lower learning rate on a dataset from institution 2 to produce a fine-tuned model, EDM 2 . Another model, EDM 3 , was trained from scratch using a training dataset composed of data from both institutions. These three models were validated on a randomly selected and unseen dataset composed of images from both institutions, for a total of 303 image pairs. The model performances were quantified using a receiver operating characteristic analysis. Due to the rarity of vertebral-body misalignments in the clinic, a minimum threshold value yielding a specificity of at least 99% was selected. Using this threshold, the sensitivity was calculated for each model, on each institution's test set separately. Results: When applied to the combined test set, EDM 1 , EDM 2 , and EDM 3 resulted in an area under curve of 99.5%, 99.4%, and 99.5%, respectively. EDM 1 achieved a sensitivity of 96% and 88% on Institution 1 and Institution 2 test set, respectively. EDM 2 obtained a sensitivity of 95% on each institution's test set. EDM 3 achieved a sensitivity of 95% and 88% on Institution 1 and Institution 2 test set, respectively. Conclusion:The proposed algorithm demonstrated accuracy in identifying off -by-one vertebral-body misalignments in CBCT-guided radiotherapy that 6410

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Anatomical Variations That Can Lead to Spine Surgery at The Wrong Level: Part II Thoracic Spine

Cited by 24 publications

References 21 publications

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part III Lumbosacral Spine

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part III Lumbosacral Spine

Definition of Normal Vertebral Morphometry Using NHANES‐II Radiographs

Development and interinstitutional validation of an automatic vertebral‐body misalignment error detector for cone‐beam CT‐guided radiotherapy

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